Provider Demographics
NPI:1700222015
Name:BLACK, AMBER R
Entity Type:Individual
Prefix:
First Name:AMBER
Middle Name:R
Last Name:BLACK
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:AMBER
Other - Middle Name:R
Other - Last Name:VAHABZADEGAN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:14700 SE 27TH CT
Mailing Address - Street 2:
Mailing Address - City:CHOCTAW
Mailing Address - State:OK
Mailing Address - Zip Code:73020-6596
Mailing Address - Country:US
Mailing Address - Phone:405-613-8848
Mailing Address - Fax:
Practice Address - Street 1:14700 SE 27TH CT
Practice Address - Street 2:
Practice Address - City:CHOCTAW
Practice Address - State:OK
Practice Address - Zip Code:73020-6596
Practice Address - Country:US
Practice Address - Phone:405-613-8848
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-05-14
Last Update Date:2013-05-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor